In clinical practice it is very easy when looking at the causes of chronic disease to focus on risk factors and markers by performing measurements and blood tests on a patient. It is well known that abnormalities in these indices can lead to low grade chronic and systemic inflammation called meta-flammation, which in turn leads to chronic disease.
In this process it is easy to blame the patient for ‘letting themselves go’ with unhealthy lifestyles such as poor nutritional choices, inactivity, smoking and alcohol dependence etc. However behind these lifestyle behaviours there are more subtle causes of chronic disease that should not be ignored. These are often referred to as the social determinants of health.
Of particular concern are current environmental issues which may involve physical, political and socioeconomic factors. These often explain unhealthy individual choices people make. People who feel left out in our society are particularly vulnerable.
In the textbook Lifestyle Medicine (3rd edition) for which I am a co-author we use the acronym MAL which stands for Meaninglessness, Alienation and Loss of culture/identity.
A hierarchy of lifestyle/environmental determinants in chronic disease “causality.”
MeaninglessnessAn iceberg analogy of the interactions between lifestyle/environmental determinants
Meaninglessness is a concept pioneered by Victor Frankl in his 1959 seminal book Man’s Search for Meaning. He had endured years in a WW2 German concentration camp and found that survival of fellow Jewish prisoners was related to the extent that individuals had meaning and purpose in life.
This could be, but not necessarily, associated with spiritual or religious beliefs. It could also spring from attachments to family, culture, occupation, interests etc. In Frankl’s case his survival depended on the meaning he attained through developing a psychotherapeutic theory around the significance of this concept called logotherapy (from the Greek logos or meaning).
There is now a growing body of literature to support the concept of deriving meaning in life being associated with better physical health, reduced risk of suicide, stroke, myocardial infarction and psychological wellbeing when faced with chronic pain. Lack of meaning can be associated with behavioral factors such as smoking, stress, inactivity, poor nutrition etc.
People who find new meaning in life through a cause, education, job, volunteering, joining a group such as a choir can improve health and emotional wellbeing.
Alienation
Alienation can result from past trauma which can be inter-generational as often seen in Indigenous communities. Factors such as genocide, stolen land, assimilation, racism, discrimination, denial of Aboriginal history and culture, stolen generations and deaths in custody can play a part.
The resulting shame and chronic stress can lead to social isolation, rejection by family, friends, peers or society. Communication by social media leading to rejection from a group can be cruel as some young people experience. This is a worsening problem particularly for school children.
With increasing inequality seen in today’s world more people are feeling left out and this can play out with political voting patterns. Those who have feelings of despair and hopelessness often have little control over their lives which in turn can have health implications.
Loneliness is becoming more common as there are more people are living alone in many age groups.
Major trauma such as after an adverse childhood experience (ACE) is also well researched resulting in health implications in later life as previously described in GPSpeak (Nov 2015).
Loss of culture and identity
Loss of culture and/or identity can arise from dispossession, displacement, conflict, climatic events and natural disasters. In Australia the health gap between our Aboriginal and non-indigenous population is well known as it is within other First Nation’s people around the world. As we take in more refugees we need to provide the health support services that take into account their loss of culture and adjustment to life in our country.
It is so easy to forget the sequelae of a natural disaster such as fire, flood, drought or war after the event, but the suffering goes on and rebuilding lives can be a struggle with mental and physical health implications. Post traumatic stress disorder seems to be increasing and is a huge burden on the health system. Suicide rates are increasing particularly in marginalised communities.
The clinician’s role
It is tempting as a GP to focus on risk factors rather than the predisposing causes of unhealthy lifestyle choices. It is hard in a 15 minute consultation to address the psychosocial factors in one’s life when there are obvious physical health issues of the day to deal with.
However, maybe we should try harder with ideas that may lead to the need for ongoing follow up consultations or referral to other health professionals. Poor compliance with our best of intentioned advice could be addressed from the MAL perspective.
Clinical Options
Here are some ideas:
Focusing on a patient’s interests, skills or passions in life can be useful. This often opens the way to refocus. It could be taking up art, sport, gardening, joining a community group or taking up a new hobby that can change lifestyle behavior.
Don’t be afraid to ask “if anything bad may have happened to you – perhaps in your childhood”. Whilst we don’t need to know the detail, to acknowledge that we know, believe and understand the implications of those past distressing event can have therapeutic benefit. This is before we give any advice or refer for further support.
Loneliness leads to an unhealthy negative state of mind that can be addressed so long as it comes from one’s intrinsic motivation.
Having a surgery environment that is warm and friendly to marginalised communities is helpful for gaining rapport. A good example is the use of art on the walls. For instance Aboriginal people feel more comfortable attending a practice that has art exhibited from their own community.
When it comes to healing, connection to one’s culture fulfills an important role and this can be achieved through art in all its forms. Also sport can play a significant role both physically, socially and culturally.
One of the founders of the NSW Rugby League Knockout Carnival, Bob Morgan a Gamilaroi man described it this way. “The Knockout was never simply about football, it was about family, it was about community, it was getting people to come together and enjoy and celebrate things rather than win the competition football”. This is a significant and popular annual cultural event since 1971.
In more recent times Aboriginal people have developed other culturally appropriate health programs that are growing in numbers attending each year. One example is the NSW Knockout Health Challenge.
Within a clinical practice shared medical appointments is another way of using group therapy to address the social determinants of health. (See GPSpeak Summer 2014)
An iceberg analogy of the interactions between lifestyle/environmental determinants
Conclusion
It is important to realise how addressing only poor nutrition, physical inactivity, smoking and alcohol abuse is just the tip of the iceberg in understanding the deeper causes of chronic disease. To bring about lifestyle and health improvements, social determinants and the more distal causes of unhealthy lifestyle habits need to be addressed.
